Letter in response to article in journal of infection: “The microbiology of chronic osteomyelitis: Changes over ten years”

Walter, Nike; Baertl, Susanne; Engelstaedter, Ulrike; Ehrenschwender, Martin; Hitzenbichler, Florian; Alt, Volker; Rupp, Markus

doi:10.1016/j.jinf.2021.09.006

Cited by 8 publications

(9 citation statements)

References 9 publications

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“…This trend is also seen in another published study, albeit with much smaller numbers [ 19 ]. Walter et al found that only 9.4% of FRI cases were culture-negative compared to 19% overall in our study, but all of these culture-negative infections were found in delayed or late FRI [ 19 ]. Our culture-negative rate is higher than other published reports [ 21 ]; however, this may be due to the high percentage of late infections in our cohort.…”

Section: Discussionsupporting

confidence: 83%

“…Indeed, increasing antimicrobial resistance worldwide [ 17 ] is also reflected in cases of osteomyelitis over time [ 18 ], although data regarding the role of antimicrobial resistance in FRI is currently lacking. Whether or not the types of pathogens isolated in FRI are time-dependent remains controversial, with just one study suggesting that there is a difference [ 11 ], whereas another more recent study found no difference [ 19 ]. Finally, a recent review of FRI management declared these time intervals as somewhat ‘arbitrary’ [ 10 ].…”

Section: Introductionmentioning

confidence: 99%

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Causative Pathogens Do Not Differ between Early, Delayed or Late Fracture-Related Infections

et al. 2022

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Fracture-related infections (FRIs) are classically considered to be early (0–2 weeks), delayed (3–10 weeks) or late (>10 weeks) based on hypothesized differences in causative pathogens and biofilm formation. Treatment strategies often reflect this classification, with debridement, antimicrobial therapy and implant retention (DAIR) preferentially reserved for early FRI. This study examined pathogens isolated from FRI to confirm or refute these hypothesized differences in causative pathogens over time. Cases of FRI managed surgically at three centres between 2015–2019 and followed up for at least one year were included. Data were analysed regarding patient demographics, time from injury and pathogens isolated. Patients who underwent DAIR were also analysed separately. In total, 433 FRIs were studied, including 51 early cases (median time from injury of 2 weeks, interquartile range (IQR) of 1–2 weeks), 82 delayed cases (median time from injury of 5 weeks, IQR of 4–8 weeks) and 300 late cases (median time from injury of 112 weeks, IQR of 40–737 weeks). The type of infection was associated with time since injury; early or delayed FRI are most likely to be polymicrobial, whereas late FRIs are more likely to be culture-negative, or monomicrobial. Staphylococcus aureus was the most commonly isolated pathogen at all time points; however, we found no evidence that the type of pathogens isolated in early, delayed or late infections were different (p = 0.2). More specifically, we found no evidence for more virulent pathogens (S. aureus, Gram-negative aerobic bacilli) in early infections and less virulent pathogens (such as coagulase negative staphylococci) in late infections. In summary, decisions on FRI treatment should not assume microbiological differences related to time since injury. From a microbiological perspective, the relevance of classifying FRI by time since injury remains unclear.

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Section: Discussionsupporting

confidence: 83%

Section: Introductionmentioning

confidence: 99%

Causative Pathogens Do Not Differ between Early, Delayed or Late Fracture-Related Infections

et al. 2022

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“…Difficult-to-treat microorganisms with a biofilm-active antibiotic resistance were present in 12 cases (10.3%) (Table 2). The pathogen distribution did not differ significantly between the subgroups [16]. Overall, the highest hypothetical sensitivity could be achieved by the combination of meropenem + vancomycin, with 95.7% of all patients showing confirmed susceptibility.…”

Section: Empiric Antimicrobial Regimes In Frimentioning

confidence: 82%

“…Recently, the microbiologic etiology in FRI has been analyzed, suggesting a similar spectrum of pathogens in early, delayed, and late FRI [16]. However, data on antimicrobial susceptibility testing and empiric antibiotic treatment strategies for FRI with respect to the onset of infection in clinical practice are still pending.…”

Section: Introductionmentioning

confidence: 99%

What Is the Most Effective Empirical Antibiotic Treatment for Early, Delayed, and Late Fracture-Related Infections?

et al. 2022

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Antibiotic treatment strategies for fracture-related infections (FRI) are often extrapolated from periprosthetic joint infections (PJI), although, in contrast to PJI, detailed analysis of pathogens and their antibiotic resistance is missing. Therefore, this study aimed to investigate antibiotic susceptibility profiles to identify effective empiric antibiotic treatment for early-, delayed-, and late-onset FRI. Patients treated for FRI from 2013 to 2020 were grouped into early (<2 weeks), delayed (3–10 weeks), and late (>10 weeks) onset of infection. Antibiotic susceptibility profiles were examined with respect to broadly used antibiotics and antibiotic combinations. In total, 117 patients (early n = 19, delayed n = 60, late n = 38) were enrolled. In early-onset FRI, 100.0% efficacy would be achieved by meropenem + vancomycin, gentamicin + vancomycin, co-amoxiclav + glycopeptide, ciprofloxacin + glycopeptide and piperacillin/tazobactam + glycopeptide. For patients with delayed FRI, the highest susceptibility was revealed for meropenem + vancomycin, gentamicin + vancomycin and ciprofloxacin + glycopeptide (96.7%). Meropenem + vancomycin was the most effective empiric antimicrobial in patients with late-onset of infection with 92.1% coverage. No subgroup differences in antibiotic sensitivity profiles were observed except for the combination ciprofloxacin + glycopeptide, which was significantly superior in early FRI (F = 3.304, p = 0.04). Across all subgroups meropenem + vancomycin was the most effective empiric treatment in 95.7% of patients with confirmed susceptibility. Meropenem + vancomycin, gentamicin + vancomycin, co-amoxiclav + glycopeptide are the best therapeutic options for FRI, regardless of the onset of infection. To avoid multidrug resistance, established antibiotic combinations such as co-amoxiclav with a glycopeptide seem to be reasonable as a systemic antibiotic therapy, while vancomycin + gentamicin could be implemented in local antibiotic therapy to reduce adverse events during treatment.

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“…With modern treatment techniques and careful attention to the principles of care, good results may be obtained with DAIR, at all time points. It has recently been shown that the microbiology of FRIs is not distinctly different when comparing early, delayed or late infections [ 34 ]. Hence, the outcome of DAIR cannot be affected by microbiological factors or antibiotic choice.…”

Section: Discussionmentioning

confidence: 99%

What Factors Affect Outcome in the Treatment of Fracture-Related Infection?

et al. 2022

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This international, multi-center study investigated the effect of individual components of surgery on the clinical outcomes of patients treated for fracture-related infection (FRI). All patients with surgically treated FRIs, confirmed by the FRI consensus definition, were included. Data were collected on demographics, time from injury to FRI surgery, soft tissue reconstruction, stabilization and systemic and local anti-microbial therapy. Patients were followed up for a minimum of one year. In total, 433 patients were treated with a mean age of 49.7 years (17–84). The mean follow-up time was 26 months (range 12–72). The eradication of infection was successful in 86.4% of all cases and 86.0% of unhealed infected fractures were healed at the final review. In total, 3.3% required amputation. The outcome was not dependent on age, BMI, the presence of metalwork or time from injury (recurrence rate 16.5% in FRI treated at 1–10 weeks after injury; 13.1% at 11–52 weeks; 12.1% at >52 weeks: p = 0.52). The debridement and retention of a stable implant (DAIR) had a failure rate of 21.4%; implant exchange to a new internal fixation had a failure rate of 12.5%; and conversion to external fixation had a failure rate of 10.3% (adjusted hazard ratio (aHR) DAIR vs. Ext Fix 2.377; 95% C.I. 0.96–5.731). Tibial FRI treated with a free flap was successful in 92.1% of cases and in 80.4% of cases without a free flap (HR 0.38; 95% C.I. 0.14–1.0), while the use of NPWT was associated with higher recurrence rates (HR 3.473; 95% C.I. 1.852–6.512). The implantation of local antibiotics reduced the recurrence from 18.7% to 10.0% (HR 0.48; 95% C.I. 0.29–0.81). The successful treatment of FRI was multi-factorial. These data suggested that treatment decisions should not be based on time from injury alone, as other factors also affected the outcome. Further work to determine the best indications for DAIR, free flap reconstruction and local antibiotics is warranted.

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Letter in response to article in journal of infection: “The microbiology of chronic osteomyelitis: Changes over ten years”

Cited by 8 publications

References 9 publications

Causative Pathogens Do Not Differ between Early, Delayed or Late Fracture-Related Infections

Causative Pathogens Do Not Differ between Early, Delayed or Late Fracture-Related Infections

What Is the Most Effective Empirical Antibiotic Treatment for Early, Delayed, and Late Fracture-Related Infections?

What Factors Affect Outcome in the Treatment of Fracture-Related Infection?

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